Current through Register Vol. 63, No. 9, September 1, 2024
(1) A carrier must offer all of its approved
nongrandfathered individual health benefit plans and plan options, including
individual plans offered through associations, to all individuals eligible for
such plans on a guaranteed issue basis without regard to health status, age,
immigration status or lawful presence in the United States. Except as provided
in section (2) of this rule:
(a) For
individual health benefit plans approved by October 1 of each calendar year for
sale in the following calendar year, a carrier may limit enrollment to October
15 to December 7 of each preceding calendar year for coverage effective on or
after January 1, 2016; and
(b)
Coverage must be effective consistent with the dates described in
45 CFR
155.410(c) and
(f).
(2)
(a)
Notwithstanding section (1) of this rule, a carrier must deny enrollment under
the following circumstances:
(A) To an
individual who is not lawfully present in the United States in a plan provided
through the health insurance exchange.
(B) To an individual entitled to benefits
under a Medicare plan under part A or B or a Medicare Choice or Medicare
Advantage plan described in 42 USC 1395W-21, if and only if
the individual is enrolled in such a plan.
(b) A carrier must enroll an individual who,
within 60 days before application for coverage with the carrier:
(A) Loses minimum essential coverage. Loss of
minimum essential coverage does not include termination or loss due to failure
to pay premiums or rescission as specified in
45 CFR
147.128. The effective date of coverage for
the loss of minimum essential must be consistent with the requirements of
45 CFR
155.420(b)(1).
(B) Gains a dependent or becomes a dependent
through marriage, birth, adoption or placement for adoption or foster care. The
effective date for coverage for enrollment under this paragraph must be:
(i) In the case of marriage, no later than
the first day of the first calendar month following the date the carrier
receives the request for special enrollment.
(ii) In the case of birth, on the date of
birth.
(iii) In the case of
adoption or placement for adoption or foster care, no later than the date of
adoption or placement for adoption or foster care.
(C) Experiences a qualifying event as defined
under section 603 of the Employee Retirement Income Security Act of 1974, as
amended.
(D) Experiences an event
described in 45 CFR
155.420(d)(4), (5), (6), or
(7). The effective date of coverage for
enrollment under this paragraph must be:
(i)
For 45 CFR
155.420(d)(4) or (d)(5),
consistent with the requirements of
45 CFR
155.420(b)(2)(iii).
(ii) For
45 CFR
155.420(d)(6) or (d)(7),
consistent with the requirements of
45 CFR
155.420(b)(1).
(E) Loses eligibility for coverage
under a Medicaid plan under title XIX of the Social Security Act or a state
child health plan under title XXI of the Social Security Act. The effective
date of coverage for enrollment under this paragraph must be consistent with
the requirements of 45 CFR
155.420(b)(1).
(3) Except as permitted
under a preexisting condition provision of a grandfathered individual plan, a
carrier may not modify the benefit provisions of an individual health benefit
plan for any enrollee by means of a rider, endorsement or otherwise for the
purpose of restricting or excluding coverage for medical services or conditions
that are otherwise covered by the plan.
(4) A carrier may offer wrap-around
occupational coverage to an accepted individual health benefit plan
applicant.
(5) A carrier may impose
an individual coverage waiting period on the coverage of certain new enrollees
in a grandfathered individual health benefit plan in accordance with ORS
743B.125. The terms of the
waiting period must be specified in the policy form and enrollee summary. The
waiting period may apply only when the carrier has determined that the enrollee
has a preexisting health condition warranting the application of a waiting
period through evaluation of the form entitled "Oregon Individual Standard
Health Statement" as set forth on the website of the Department of Consumer and
Business Services at dfr.oregon.gov.
(6) A carrier may treat a request by an
enrollee in an individual health benefit plan to enroll in another individual
plan as a new application for coverage.
(7) Unless otherwise required by law and
except as provided in section (8) of this rule, a carrier must implement a
modification of a nongrandfathered individual health benefit plan required by
statute on the next anniversary or fixed renewal date of the plan that occurs
on or after the operative date of the statutory provision requiring the
modification.
(8) For a
grandfathered individual health benefit plan:
(a) Unless otherwise required by law, a
carrier must implement a modification required by statute on the first day of
the calendar year that occurs on or after the operative date of the statutory
provision requiring the modification.
(b) A carrier must eliminate and deem
ineffective a rider or endorsement in effect for an enrollee based on the
actual or expected health status of the enrollee and that excludes coverage for
diseases or medical conditions otherwise covered by the plan as of the next
renewal date;
(c) If an enrollee
who is subject to a preexisting condition provision has a rider or endorsement
eliminated in accordance with subsection (a) of this section, the enrollee's
medical condition that is subject to the rider or endorsement may be subject to
the preexisting conditions provision of the plan, including the prior coverage
credit provisions;
(9)
In accordance with applicable federal law, a carrier may not deny continuation
or renewal of an individual health benefit plan based on Medicare eligibility
of an individual but an individual health benefit plan may contain a Medicare
non-duplication provision.
(10)
Violation of this rule is an unfair trade practice under ORS
746.240.
Statutory/Other Authority: ORS
731.244, ORS
743.745 &
743.769
Statutes/Other Implemented: ORS
743.745 &
743.766 -
743.769
